Independent investigation: Brenda Lindley, Northfleet (2007)

The Trust should ensure there is guidance in place detailing the responsibility of clinicians to ensure that service users are monitored during changes to psychiatric medication and have process in place to monitor adherence to this on an ongoing basis. Read more The Trust should ensure there is guidance in place detailing the responsibility of clinicians to ensure that service users are monitored during changes to psychiatric medication and have process in place to monitor adherence to this on an ongoing basis. Show less

The Trust should ensure that formal clinical risk assessments take place on every occasion that service users are transferred between care teams or are discharged from the services of the Trust, as in the Trust policy.

The Trust should ensure there are clear standards in place detailing what information should be sent to GP’s when a service user is discharged back to their sole care, and should continue to audit ongoing compliance with this.

The Trust should ensure that one of the functions of the incident co-ordination group is to devise and agree a communications plan to ensure that appropriate service users and their families are communicated with in a co-ordinated way. This must … Read more The Trust should ensure that one of the functions of the incident co-ordination group is to devise and agree a communications plan to ensure that appropriate service users and their families are communicated with in a co-ordinated way. This must extend to retaining contact details for key family members of people involved in Serious Incidents so they can be contacted at a later date if necessary. Show less

The Trust should conduct an audit to ensure compliance with National Patient Safety Agency Independent Investigations of Serious Patient Safety Incidents in Mental Health 2008

The Trust should undertake a review to examine the efficacy of the processes in place for the learning and sharing of lessons learned to establish their efficacy